Building expertise: structured training and certification

Interpretation quality is just as critical as acquisition quality, since variability in reader performance remains one of the key determinants of diagnostic accuracy [35,36,37]. The prostate MRI learning curve is steep, and diagnostic confidence strongly depends on the reader’s experience. According to consensus statements, including the ESUR/ESUI recommendations [15, 38,39,40,41,42]:

A minimum of 50–150 supervised cases is required before performing independent reporting.

Around 400 cases mark the threshold for a beginner.

Typically, more than 1000 cases are needed to reach expert-level performance.

Continued experience of more than 150 cases per year is recommended to maintain proficiency.

These thresholds serve as guidance for training programmes and certification pathways. Formalised training and quality assessment, such as the ESUR/ESR Certification in Prostate MRI, and continuing medical education are essential to maintain consistency across centres and sustain quality. To support broader dissemination and skill development, the ESUR Prostate MRI Working Group is planning ongoing educational initiatives, including hands-on image-quality workshops and focused sessions at major radiology meetings such as the ESUR Annual Symposium, along with dedicated prostate-focused training through the ESUR Prostate MRI Course. These activities aim to facilitate international knowledge transfer and encourage adoption of the three-step framework beyond the ESUR network. In the longer term, the framework may serve as a model that can be adapted across diverse healthcare systems, supporting broader international implementation of prostate MRI quality standards.

Patient information and structured reporting

Accurate interpretation requires access to a core clinical dataset, ideally provided in the referral request or through the electronic health record. Essential details include PSA (and, where available, PSA kinetics), history of urinary tract infection, use of 5α-reductase inhibitors, prior androgen deprivation therapy, previous radiotherapy or focal ablation, intravesical Bacillus Calmette-Guérin, and prior biopsy results. Previous imaging is also critical, particularly for men in active surveillance or screening programmes [43].

Structured reporting templates ensure that these details, along with imaging findings, are consistently documented. PI-RADS v2.1 specifies that reports should include prostate volume (for PSA density), describe up to four suspicious lesions, and for each lesion provide location, size in millimetres, PI-RADS category, and features of extraprostatic extension. Lesion size should be measured according to PI-RADS rules: largest dimension on axial images (minimum), with sagittal/coronal measurements if larger; peripheral zone lesions on the ADC map; transition zone lesions on T2W; or, if needed, on whichever sequence best depicts the lesion. Optionally, three orthogonal dimensions or software-derived volume may be reported. The report should specify the sequence and series used, and a standardised diagram or sector map is recommended to facilitate communication with urologists.

Building expertise depends not only on case numbers and certification but also on continuous feedback linking imaging to pathology and outcomes—mechanisms best embedded within institutional quality assurance frameworks (see “Institutional quality assurance frameworks: from benchmarks to multidisciplinary integration” section).

Institutional quality assurance frameworks: from benchmarks to multidisciplinary integrationPI-RADS 3 frequency as a practical indicator

The proportion of examinations categorised as PI-RADS 3 offers a pragmatic, biopsy-independent indicator of quality. The frequency of PI-RADS 3 reflects both the reader’s confidence and image quality. PCa detection rates, on the other hand, are strongly influenced by referral patterns and clinical decision-making.

Reported PI-RADS 3 rates vary considerably. A persistently high institutional PI-RADS 3 rate should first trigger a formal audit of technical image quality using an objective tool like PI-QUAL v2. This approach addresses the root cause (i.e., suboptimal image data) rather than just the symptom of interpretive uncertainty. Evidence confirms a direct correlation between better image quality (i.e., higher PI-QUAL scores) and improved diagnostic confidence, resulting in a significant reduction in indeterminate PI-RADS 3 calls. In the expert-driven, 3 T 4 M trial, PI-RADS 3 lesions appeared in 6% and 11% of cases, for mpMRI and bpMRI, respectively [44].

These considerations apply primarily to the setting for early detection, where the prevalence of csPCa ranges from 30 to 50% [45]. In population-based screening with lower disease prevalence, an optimal “recall rate” for PI-RADS 3 has not been established. Determining these thresholds requires prospective studies balancing diagnostic benefits with downstream tests, similar to other cancer screening programmes.

Practical strategies to ensure an appropriate PI-RADS 3 level include expert re-review, linking PI-RADS 3 cases with histopathological feedback, selective use of DCE-MRI by less experienced readers, and institutional audits that track PI-RADS 3 proportions over time [46,47,48,49].

Finally, it is essential to score PI-QUAL 1 examinations (i.e., insufficient quality) as non-diagnostic rather than assigning a PI-RADS 3 score.

Feedback, discrepancy reconciliation, and multidisciplinary integration

High-quality prostate MRI requires feedback loops that extend beyond image acquisition and reporting volumes. Reporting accuracy must be judged against patient outcomes, through structured discrepancy audits and multidisciplinary case reviews with urologists, pathologists and oncologists. Linking interpretations to biopsy or prostatectomy findings—particularly in centres with targeted biopsy or whole-mount correlation—ensures accountability and identifies areas for improvement.

When MRI results diverge from pathology—for example, a PI-RADS 5 lesion with negative biopsy (Fig. E9) or PI-RADS 1–2 with biopsy-proven csPCa—formal correlation is mandatory to determine whether the discrepancy reflects acquisition issues, interpretive error, or inherent MRI limitations. Embedding such reconciliation in QA dashboards, discrepancy meetings, or multidisciplinary discussions strengthens protocols, reduces unnecessary biopsies and overdiagnosis, and ultimately increases confidence in prostate MRI [50, 51]. Beyond technical accuracy, QA should also assess downstream clinical impact—for example, whether reports lead to appropriate biopsy recommendations. Incorporating these elements ensures that MRI reporting is not only internally consistent but also fully integrated into the wider prostate cancer care pathway [1, 43].

Collaborative quality improvement initiatives

Recently, the ACR launched the Prostate MR Image Quality Improvement Collaborative, uniting multidisciplinary teams to standardise prostate MRI protocols (using the PI-QUAL score) and implement targeted interventions like protocol refinement, patient preparation, and education [52]. This increased with the proportion of good-quality examinations from 67% to 87%, showing system-level QA initiatives improve image quality and protocol adherence [53].

Key institutional QA metrics

At the institutional level, QA efforts should focus on a few measurable benchmarks (Table 3): PI-QUAL scores, PI-RADS score 3 call rates, detection rates of csPCa (Grade Group ≥ 2), and radiology-pathology discrepancy audits. These metrics should inform feedback systems, like double-reading discordant cases, discrepancy meetings, and dashboards. QA must remain flexible, integrating acquisition, interpretation, and outcomes into a continuous quality-improvement cycle to enhance diagnostic consistency and institutional accountability. In some settings, operator experience—often reflected by the proportion of positive MRI-targeted biopsies using fusion or in-bore approaches—may serve as an additional quality indicator, linking interpretive accuracy with procedural performance.

Table 3 Proposed quality indicators and corrective actions for prostate MRIThe QA workforce: beyond the radiologist

Technologists and radiographers serve as the frontline in QA, handling patient preparation and spotting artefacts in real time. On-table recognition of suboptimal sequences enables on-table correction, such as switching the phase-encoded direction, with on-table QA [54]. Experienced technologists can evaluate prostate MRI quality with agreement levels similar to radiologists, demonstrating their ability to detect problems and make immediate corrections [55]. This offers a solid, evidence-based reason for empowering technologists to perform on-table QA and repeat inadequate sequences before the patient leaves the scanner.

Empowering technologists to flag deviations and repeat inadequate sequences is essential to prevent non-diagnostic examinations. Future certification programmes for technologists and radiographers in prostate MRI could standardise training and support a capable workforce, especially if MRI is used in population-based screening.

MRI physicists safeguard technical robustness by calibrating scanners, troubleshooting hardware/software, and maintaining cross-platform consistency.

Radiologist-patient communication

Radiologist–patient communication is an often-overlooked but crucial aspect of prostate MRI quality. The ACR Prostate Collaborative identified inadequate communication as a leading cause of poor compliance with preparation instructions. Providing clear, timely guidance significantly improves image quality. Structured reports, patient-friendly summaries, and selective consultations enhance transparency, accountability, and trust in imaging-driven care. When patients understand why surveillance may be preferred over biopsy, they are more likely to accept MRI-based monitoring.

Perlis et al introduced the Patient-Centred Prostate MRI Report, which improved comprehension and engagement compared with conventional reports [56]. A pilot trial confirmed that simplified, patient-oriented summaries reduced decisional conflict and clarified management pathways [57]. Studies by Merriel et al and Sutherland et al found that men, particularly those on active surveillance, valued clear explanations of MRI findings but often encountered fragmented communication [58, 59]. Brief pre-procedural interactions between radiologists and patients were associated with reduced anxiety and greater satisfaction [60]. Limitations include time constraints in busy practices and variation in institutional expectations for radiologists.